Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

BACKGROUND: Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. METHODS: Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. RESULTS: Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). CONCLUSION: Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast Tissue Expanders with Magnetic Ports: Clinical Experience at 1.5 T.

BACKGROUND: The purpose of this study was to evaluate breast tissue expanders with magnetic ports for safety in patients undergoing abdominal/pelvic magnetic resonance angiography before autologous breast reconstruction. METHODS: Magnetic resonance angiography of the abdomen and pelvis at 1.5 T was performed in 71 patients in prone position with tissue expanders with magnetic ports labeled "MR Unsafe" from July of 2012 to May of 2014. Patients were monitored during magnetic resonance angiography for tissue expander-related symptoms, and the chest wall tissue adjacent to the tissue expander was examined for injury at the time of tissue expander removal for breast reconstruction. Retrospective review of these patients' clinical records was performed. T2-weighted fast spin echo, steady-state free precession and gadolinium-enhanced spoiled gradient echo sequences were assessed for image artifacts. RESULTS: No patient had tissue expander or magnetic port migration during the magnetic resonance examination and none reported pain during scanning. On tissue expander removal (71 patients, 112 implants), the surgeons reported no evidence of tissue damage, and there were no operative complications at those sites of breast reconstruction. CONCLUSION: Magnetic resonance angiography of the abdomen and pelvis in patients with certain breast tissue expanders containing magnetic ports can be performed safely at 1.5 T for pre-autologous flap breast reconstruction perforator vessel mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

To Resect or Not to Resect: The Effects of Rib-Sparing Harvest of the Internal Mammary Vessels in Microsurgical Breast Reconstruction.

BACKGROUND: The internal mammary vessels are the most commonly used recipients for microsurgical breast reconstructions. Often, the costal cartilage is sacrificed to obtain improved vessel exposure. In an effort to reduce adverse effects associated with traditional rib sacrifice, recent studies have described less-invasive, rib-sparing strategies. METHODS: After obtaining institutional review board's approval, a retrospective review of all patients undergoing microsurgical breast reconstruction at a single institution between November 2007 and December 2013 was conducted. Patients were divided into two cohorts for comparison: rib-sacrificing and rib-sparing internal mammary vessel harvests. RESULTS: A total of 547 reconstructions (344 patients) met inclusion criteria for this study. A total of 64.9% (n = 355) underwent rib-sacrificing internal mammary vessel harvest. Cohorts were similar in baseline patient characteristics, indications for surgery, and cancer therapies. However, patients undergoing rib-sparing reconstructions had significantly shorter operative times (440 vs. 476 minutes; p < 0.01), and significantly less postoperative pain on postoperative day (POD) 1 (2.8/10 vs. 3.4/10; p = 0.033) and POD2 (2.4/10 vs. 3.0/10; p = 0.037). Furthermore, patients undergoing rib-sparing techniques had greater incidence of fat necrosis requiring excision (12.5 vs. 2.8%; p < 0.01) and a trend toward higher incidence of hematoma, venous thrombosis, and arterial thrombosis when compared with rib-sacrificing patients. CONCLUSIONS: Rib-sparing harvest of internal mammary vessels is a feasible technique in microsurgical breast reconstruction. However, given the significant increase in fat necrosis requiring surgical excision, the trend toward increased postoperative complications, and no significant difference in postoperative revision rates, the purported benefits of this technique may fail to outweigh the possible risks.

Microsurgical breast reconstruction in thin patients: the impact of low body mass indices.

BACKGROUND: The purpose of this investigation was to examine patients with low body mass index (BMI) regarding the feasibility to perform autologous breast reconstruction in such patients, as well as to determine optimal donor sites and evaluate outcomes accordingly. PATIENTS AND METHODS: All patients undergoing microsurgical breast reconstruction were divided into three cohorts based on BMI. Group 1 included patients with BMI greater than or equal to 22 kg/m(2) and was defined "low-normal BMI." Patients with BMI 22 to 25 kg/m(2) were placed in Group 2, labeled as "high-normal BMI." Group 3, defined as "overweight," included patients with BMI greater than 25 kg/m(2), but less than 30 kg/m(2). Patients were then analyzed based on demographics, breast cancer history, intraoperative details, complications, and revisionary surgeries. F-tests, chi-square goodness-of-fit tests, and Freeman-Halton extension of the Fisher exact tests were used for statistical analysis. RESULTS: During the study period, a total of 259 reconstructions were performed. Group 1 included 30 patients (n = 49 flaps), Group 2 included 58 patients (n = 98 flaps), and Group 3 included 69 patients (n = 112 flaps). Patients undergoing nipple-areolar sparing mastectomy were more likely to be in Groups 1 (39% [n = 19]) and 2 (37% [n = 37]) as compared with Group 3 (14.2% [n = 16]) (p < 0.001) as compared with the overweight cohort. Patients with increasing BMI were more likely to undergo abdominally based free flaps as compared with alternative donor sites (Group 1 = 2.26, Group 2 = 7.9, Group 3 = 27 [p < 0.001]). CONCLUSIONS: Abdominally based free flaps are possible in the majority of patients, however alternative harvest sites have to be used more frequently in low BMI patients.

Autologous breast reconstruction: preoperative magnetic resonance angiography for perforator flap vessel mapping.

BACKGROUND: Selection of a vascular pedicle for autologous breast reconstruction is time consuming and depends on visual evaluation during the surgery. Preoperative imaging of donor site for mapping the perforator artery anatomy greatly improves the efficiency of perforator selection and significantly reduces the operative time. In this article, we present our experience with magnetic resonance angiography (MRA) for perforator vessel mapping including MRA technique and interpretation. METHODS: We have performed over 400 MRA examinations from August 2008 to August 2013 at our institution for preoperative imaging of donor site for mapping the perforator vessel anatomy. Using our optimized imaging protocol with blood pool magnetic resonance imaging contrast agents, multiple donor sites can be imaged in a single MRA examination. Following imaging using the postprocessing and reporting tool, we estimated incidence of commonly used perforators for autologous breast reconstruction. RESULTS: In our practice, anterior abdominal wall tissue is the most commonly used donor site for perforator flap breast reconstruction and deep inferior epigastric artery perforators are the most commonly used vascular pedicle. A thigh flap, based on the profunda femoral artery perforator has become the second most used flap at our institution. In addition, MRA imaging also showed evidence of metastatic disease in 4% of our patient subset. CONCLUSION: Our MRA technique allows the surgeons to confidently assess multiple donor sites for the best perforator and flap design. In conclusion, a well-performed MRA with specific postprocessing provides an accurate method for mapping perforator vessel, at the same time avoiding ionizing radiation.

In vitro assessment of MRI issues at 3-Tesla for a breast tissue expander with a remote port.

OBJECTIVES: A patient with a breast tissue expander may require a diagnostic assessment using magnetic resonance imaging (MRI). To ensure patient safety, this type of implant must undergo in vitro MRI testing using proper techniques. Therefore, this investigation evaluated MRI issues (i.e., magnetic field interactions, heating, and artifacts) at 3-Tesla for a breast tissue expander with a remote port. METHODS: A breast tissue expander with a remote port (Integra Breast Tissue Expander, Model 3612-06 with Standard Remote Port, PMT Corporation, Chanhassen, MN) underwent evaluation for magnetic field interactions (translational attraction and torque), MRI-related heating, and artifacts using standardized techniques. Heating was evaluated by placing the implant in a gelled-saline-filled phantom and MRI was performed using a transmit/receive RF body coil at an MR system reported, whole body averaged specific absorption rate of 2.9-W/kg. Artifacts were characterized using T1-weighted and GRE pulse sequences. RESULTS: Magnetic field interactions were not substantial and, thus, will not pose a hazard to a patient in a 3-Tesla or less MRI environment. The highest temperature rise was 1.7°C, which is physiologically inconsequential. Artifacts were large in relation to the remote port and metal connector of the implant but will only present problems if the MR imaging area of interest is where these components are located. CONCLUSIONS: A patient with this breast tissue expander with a remote port may safely undergo MRI at 3-Tesla or less under the conditions used for this investigation. These findings are the first reported at 3-Tesla for a tissue expander.

Stacked profunda artery perforator flaps for unilateral breast reconstruction: a case report.

A patient with a severe case of Poland syndrome presented with a painful capsular contracture from a previous implant-based breast reconstruction. She desired the implant to be removed and to proceed with autologous reconstruction, sizeable enough to match the volume of her contralateral breast. A paucity of abdominal donor tissue combined with the patient's hesitancy to acquire an anterior scar excluded this location as a free tissue transfer option. As an alternative donor site, the profunda artery perforator (PAP) flap was chosen. Bilateral PAP flaps were harvested and stacked using anterograde and retrograde anastomoses to the internal mammary vessels. Enough volume was present to fill her chest wall concavity and provide adequate projection to achieve symmetry with her contralateral breast. Her donor sites healed well and remained inconspicuous, without generating difficulties sitting. In conclusion, stacked PAP flaps provide an excellent alternative to an abdominal donor site for achieving large volume unilateral breast reconstruction.

Microsurgical breast reconstruction for nipple-sparing mastectomy.

BACKGROUND: Nipple-sparing mastectomy warrants thorough preoperative evaluation to effectively achieve risk reduction, high patient satisfaction, and improved aesthetic outcome. To the authors' knowledge, this review represents the largest series of microsurgical breast reconstructions following nipple-sparing mastectomies. METHODS: All patients undergoing nipple-sparing mastectomy with microsurgical immediate breast reconstruction treated at New York University Medical Center (2007-2011) were identified. Patient demographics, breast cancer history, intraoperative details, complications, and revision operations were examined. Descriptive statistical analysis, including t test or regression analysis, was performed. RESULTS: In 51 patients, 85 free flap breast reconstructions (n = 85) were performed. The majority of flaps were performed for prophylactic indications [n = 55 (64.7 percent)], mostly through vertical incisions [n = 40 (47.0 percent)]. Donor sites included abdominally based [n = 66 (77.6 percent)], profunda artery perforator [n = 12 (14.1 percent)], transverse upper gracilis [n = 6 (7.0 percent)], and superior gluteal artery perforator [n = 1 (1.2 percent)] flaps. The most common complications were mastectomy skin flap necrosis [n = 11 (12.7 percent)] and nipple necrosis [n = 11 (12.7 percent)]. There was no correlation between mastectomy skin flap or nipple necrosis and choice of incision, mastectomy specimen weight, body mass index, or age (p > 0.05). However, smoking history was associated with nipple necrosis (p < 0.01). CONCLUSIONS: This series represents a high-volume experience with nipple-sparing mastectomy followed by immediate microsurgical reconstruction. When appropriately executed, it can deliver low complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nipple-sparing mastectomy and immediate free-flap reconstruction in the large ptotic breast.

Because of increased risk for nipple necrosis, many surgeons believe large ptotic breasts to be a relative contraindication to nipple-sparing mastectomy (NSM). A retrospective review was performed on 85 consecutive patients who underwent NSM with 141 immediate perforator free-flap breast reconstructions. We analyzed the subset of patients with large ptotic breasts, defined as cup size C or greater, sternal notch to nipple distance greater than 24 cm and grade 2 or 3 breast ptosis. Of the 85 patients, 19 fit the inclusion criteria. Breast cup size ranged from 34C to 38DDD. There was 1 case of nipple necrosis in the patient with previous breast radiation (5%), 1 hematoma (5%), and no flap losses. Five (26%) patients underwent subsequent mastopexy or breast reduction, a mean of 6.6 months after the primary procedure. We demonstrate that NSM and free-flap breast reconstruction can be safely and reliably performed in selected patients.

Breast reconstruction with the profunda artery perforator flap.

BACKGROUND: The use of perforator flaps has allowed for the transfer of large amounts of soft tissue with decreased morbidity. For breast reconstruction, the deep inferior epigastric perforator flap, the superior and inferior gluteal artery perforator flaps, and the transverse upper gracilis flap are all options. The authors present an alternative source using posterior thigh soft tissue based on profunda artery perforators, termed the profunda artery perforator flap. METHODS: Preoperative imaging helps identify posterior thigh perforators from the profunda femoris artery. These are marked, and an elliptical skin paddle, approximately 27 × 7 cm, is designed 1 cm inferior to the gluteal crease. Dissection proceeds in a suprafascial plane until nearing the perforator, at which point subfascial dissection is performed. The flap has a long pedicle (approximately 7 to 13 cm), which allows more options when performing anastomosis at the recipient site. The long elliptical shape of the flap allows coning of the tissue to form a more natural breast shape. RESULTS: All profunda artery perforator flaps have been successful. The donor site is well tolerated and scars have been hidden within the gluteal crease. Long-term follow-up is needed to evaluate for possible fat necrosis of the transferred tissue. CONCLUSIONS: The authors present a new technique for breast reconstruction with a series of 27 flaps. This is an excellent option when the abdomen is not available because of the long pedicle, muscle preservation, ability to cone the tissue, and hidden scar. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Routine use of microvascular coupling device for arterial anastomosis in breast reconstruction.

BACKGROUND: Although microvascular coupling devices are used routinely and successfully for venous anastomosis, there are few published reports demonstrating their efficacy for performing arterial anastomosis. It has been the senior author's (C.Y.A.) preference to perform arterial anastomosis using the microvascular coupling device when feasible. METHODS: All microsurgical breast reconstructions performed by the senior author at the New York University Medical Center between 1998 and 2004 were retrospectively reviewed. A total of 60 patients underwent microsurgical breast reconstruction, of which 20 were bilateral, for a total of 80 flaps. RESULTS: Of the 80 flaps performed, there were 47 muscle-sparing TRAM and 22 deep inferior epigastric perforator (DIEP) flaps, and 11 were superior gluteal flaps. Arterial coupling was successfully performed in 60 of 69 flaps based on the deep inferior epigastric artery (87%) and 2 of 11 gluteal flaps (18%); arterial coupling was performed successfully 62 of 74 times (83.9%) when the thoracodorsal artery was the recipient vessel and never performed when the internal mammary artery was the recipient vessel. The overall flap success rate was 100%. CONCLUSIONS: In our large series, we were able to perform a coupled arterial anastomosis in nearly 80% of the cases, without the loss of any flaps. With proper vessel selection and sufficient experience using the microvascular coupler, arterial coupling may be performed in an expeditious, safe, and reliable fashion with minimal morbidity. Though not commonly practiced, use of the coupling device for arterial anastomosis can provide significant time savings, especially in bilateral breast reconstructions.